Period poverty: The perceptions and experiences of impoverished women living in an inner-city area of Northwest England

Background The menstrual needs of girls and women are important to health, education, and well-being. Unmet need and harm from poor menstrual health in low-and- middle-income countries have been documented, but with little empirical research undertaken in high income countries. Continuing austerity in the UK suggests menstruators are likely more vulnerable to ‘period poverty’ than previously, with the COVID-19 pandemic assumed to exacerbate the situation. Aim To explore the menstrual experiences and perceptions of women in the UK who are living under circumstances of deprivation, alongside views of staff working in organisations supporting these women, to understand whether women’s menstrual needs are met. Methods A qualitative study was conducted in an inner-city in NW England. Three focus group discussions and 14 in-depth interviews were conducted across three study sites supporting impoverished women. Data was analysed thematically. Results Themes were: reflections on menstruation; affordability of products; access to public facilities; organisational support; potential solutions. Many women perceived menstruation as a burden in three aspects: physical discomfort and pain; psychological anxiety; and shame and stigma. Managing menstruation was difficult due to cost relative to low incomes, with food, heating and lighting prioritised, leaving women improvising with materials or wearing products for longer than desired. Most suggested that products should be free, often remarking if men required similar items this would happen. Most women were unaware supporting organisations provided free products. Staff felt the small range of products offered did not meet client needs and were ill-prepared to have conversations on products and clients’ menstrual needs. Conclusion Impoverished women lack the necessary resources to manage their menses well which negatively impacts their health and brings stress, embarrassment, and shame. Support, including access to free products, is needed at both local and national level to help impoverished women manage their menstrual hygiene.


Introduction
The menstrual needs of girls and women are increasingly recognized as an important issue for their health, education, employment, and well-being [1]. Much of the evidence-base to date has demonstrated unmet need and harm from poor menstrual health and hygiene (MHH) among girls in low-and-middle income countries (LMIC) [2] The term 'menstrual health and hygiene' has been described as the needs experienced by people who menstruate, including having safe and easy access to the information, supplies, and infrastructure needed to manage their periods with dignity and comfort (menstrual hygiene management) as well as the systemic factors that link menstruation with health, gender equality, empowerment, and beyond [1]. An inadequate supply of water, hygiene, and sanitation (WASH) facilities, a lack of information about menstruation and its management, and a lack of menstrual sanitary products affect the ability to manage menstruation hygienically, comfortably, and safely, impacting on psychosocial well-being, and sexual and reproductive health. Menstrual stigmas and taboos create further challenges [3].
Until recently, efforts to improve MHH have largely focused on the needs of schoolgirls, and to a lesser extent, women in LMIC, with the assumption that the challenges for girls and women in highincome countries (HIC) are fewer and perhaps less significant [2]. However, increasing divisions in wealth disparity among populations in HIC have highlighted possible struggles for some sections of society to maintain basic levels of MHH [4]. The term 'period poverty' has been widely adopted, denoting an individual's need for menstrual products without adequate funds to purchase them [4].
Relying largely on anecdotal evidence to provide impetus, media campaigns have been established to generate awareness of period poverty to improve access to affordable menstrual products for all menstruators as a basic human right, but stigma and societies attitudes also need to change [5]. In the UK, advocacy such as Pink Protest and the Red Box, alongside presentations at Parliament have resulted in legislation to provide free menstrual products in UK primary and secondary schools, while other campaigns have had some measure of success.
Empirical evidence on period poverty in HIC remains rather scant. A recent systematic review highlighted that most research on menstruation in HIC were designed to 'understand the constructed meanings of menstruation' rather than informing practice or policy, despite the current drive to introduce campaigns and programmes to combat period poverty. Just six qualitative studies were identified that targeted participants of low-income status, with the authors concluding that to date there is insufficient evidence on the needs of marginalized and impoverished women [4]. The few studies conducted, mostly with a US focus, suggest a substantial proportion of respondents report period poverty on occasion, with a core group unable to purchase sufficient menstrual products every month. A quantitative study among US women on low incomes found 64% reported period poverty during the previous year, a monthly occurrence for one fifth of respondents [6] .
Another study among American women found that 81% of women receiving treatment for substance abuse reported 'menstrual poverty' [7]. Both studies found a significant association between period poverty and food insecurity, which was also reported in a small study of 58 high school students [8]. Nearly half of the students were unable to afford products during at least one menses in the school year, including 12% unable to afford them 'most' months [8]. A recent study found one quarter of 471 college students reported period poverty in the past year, including 10% for whom it was a monthly occurrence [9]. A phenomenological study interviewed 40 'vulnerable' women in the UK, most describing their experience of menstruation in a negative manner and disclosed a need for privacy in self-care, as well as access to menstrual products [10]. Having to ask friends or staff for products in institutional settings was a common but shameful experience. Many resorted to makeshift absorbents such as toilet tissue; others resorted to shoplifting to meet their needs. Two qualitative studies among homeless women in the US similarly reported women were reduced to shoplifting for supplies or going without food in order to purchase them [11,12].
Similarly, Kuhlman and colleagues found many low-income participants relied on donations at times and reported using cloth, rags, tissue paper, or paper towels as absorbents when necessary [6].
Some reported they had to choose between purchasing food or appropriate menstrual products.
Similar experiences were documented in the report by 'No More Taboo', a not for profit enterprise, who interviewed 37 women from low-income backgrounds, and found that half the sample reported menstrual products as too expensive, with a quarter having to improvise with t-shirts, toilet roll and nappies [13]. Women also reported suffering physical symptoms, stigma and embarrassment. Other studies have noted use of child nappies and incontinence sheets to deal with heavy bleeding [14,15].
The current COVID-19 pandemic has meant a shortage of menstrual product supplies, price increases, closing of public toilets as well as close confinement, and thus reduced privacy, in many domestic households. With continuing austerity and the subsequent increase in demand for foodbanks and homeless shelters, women and girls in the UK and elsewhere appear more vulnerable to menstrual hygiene issues than ever before [16]. Thus, despite recent policy changes, formal research evaluating the scope and health risks associated with period poverty in the UK is required to determine the wider public health implications among the most impoverished populations, and to examine whether the recent policy changes go far enough.
The present study aimed to explore the menstrual experiences, needs and perceptions of women living in circumstances of deprivation, through engagement with women and with local partners assisting with their welfare needs. We also aimed to gather perspectives from partner organisation staff to help contextualize their understanding of women in need and assess any met or unmet support they provide, along with any other concerns they identified.

Study design:
This was a qualitative study using focus group discussions (FGD) and in-depth interviews (IDI) among women living in circumstances of deprivation, and staff volunteering or working in services assisting such women.

Study setting:
The study was set in a city in northwest England, ranked within the top 5 most deprived areas in England. Three organisations were purposively chosen to represent women living in impoverished circumstances, along with staff who work within the organisations. Site 1 is a hostel for homeless women; site 2 falls under 'Approved Premises' which provides care and services for women after incarceration; and site 3 is a foodbank within the inner-city which caters for people on low-incomes, including those who become unemployed. Site 3 includes women who may have more settled accommodation. Sites 1 and 2 are referred to as 'supported accommodation sites' throughout the study.

Study tools:
The content of the FGD and IDI guides was informed by a literature and media review and developed by the research team.
The FGD and IDI topic guides began with the question "Can you tell us what menstruation means to you?" which aimed to open the discussion around menstruation and give the researchers an idea of the participants first thoughts on the subject. Further topics covered menstrual symptoms, the lead up to a period, access to menstrual products, and WASH. The topic guide ended by inviting opinions on any changes the interviewee would like to see. Topic areas for staff IDI included the nature of their service, the type and needs of service users, the provision of any menstrual health products or services, unmet menstrual needs, suggestions for any menstrual health improvements.

Eligibility:
Women were eligible to participate if they were 18 years or older, had reached menarche but not menopause, and had a recent menses (within the last three months). Staff were required to be 18 years or older. As they were not discussing their own experiences with menstruation but representing organizational perspectives and their experience as staff, there were no eligibility criteria pertaining to their own menses, and both female and male staff were equally eligible.

Sampling:
Purposive sampling was used for the FGDs and convenience sampling was used to sample for the IDI.

Participant recruitment:
For the FGDs, a member of staff from each site identified and approached potential participants on our behalf. They provided written information, answered any initial queries and checked eligibility. They suggested a mutually convenient time and date for the FGD which was held in a private room at that site. For IDIs with women, researchers attended foodbanks on selected days, and recruited women opportunistically after handing out fliers outlining the project.
They answered any questions that women had and arranged an interview time for those who were agreeable and met the inclusion criteria. Staff IDI were arranged through first discussion with staff in their organisation, with a follow-up by phone to arrange an interview time.

Data Collection:
The research team collected data between February and March 2020. One of the authors (LM), provided training / re-training to all data collectors covering the principles of qualitative data collection, use of interview guides and ethical considerations. The IDI were conducted by one of five members of the research team (AB, CG, CK, PPH, SG), the FGD were moderated by LM with AB or CG acting as notetaker. in the case of the FGDs, to provide any missing participant numbers where possible. Data were analysed by thematic analysis providing a systematic framework for analysing qualitative data [17].
A coding framework was drafted separately by three members of the research team (MB, PPH, LM) following reading and re-reading of the transcripts to gain data familiarity. The researchers compared, discussed, and assimilated the coding frameworks into one. MB then coded all relevant data using the framework before organizing these into overarching themes and subthemes. This involve and being given the opportunity to ask further questions. These were done verbally as we anticipated some participants may be illiterate.

Participant Characteristics:
A total of 32 women and 5 staff, including one male, participated in the study; 23 of whom contributed to FGD and 14 to IDI, with recruitment ending sooner than anticipated due to COVID-19 restrictions (Table 1). For quotes, an assigned code defines the IDI or FGD. P [number] was used to represent the individual participants in an FGD with Px denoting missing participant number. M represents the FGD moderator, whilst I denotes the interviewer.  Five themes were derived from the data. These were: reflections on menstruation, affordability of menstrual products; access to public WASH facilities; organisational support; potential solutions.

Reflections on menstruation:
Invariably, women's narratives, (from both FGDs and IDIs) expressed negative perceptions of menstruation, suggesting that they experienced it first and foremost as a burden. The encumbrance comprised three key aspects: physical discomfort and pain (predominantly the first aspect they spoke of); psychological disturbance; and the stigma and shame associated with menstruation.
Many women spoke of their own trials with heavy menstruation, the associated pain and the impact this had on their lives, including needing time off work, being bedridden with pain, or generally being unable to function as usual during the onset or first few days of menses. Psychological symptoms such as low mood, anger and worry before and during menstruation were described in all FGDs, and over half of the interviews. These symptoms were often a concern; occasionally the emotions they evoked were felt to be out of the individuals' control. (FGD03 -P3 Supported accommodation).
We noted the participants making positive comments did not report physically painful or disruptive periods.
The overall participant view was that menstruation was a burden that women had to endure. The phrase, "have to just get on with it" was mentioned multiple times in different FGDs and IDIs.
Affordability of menstrual products: Managing menstruation was difficult for many women because of the heavy financial cost relative to their incomes. Most of our participants were receiving Universal Credit from the government, a payment made to help with living costs for those out of work, unable to work or on low income.
Women across both FGDs and IDIs reported the amount received was insufficient for daily living and spoke of how they struggled to manage their finances, particularly those supporting a family.
Menstrual products were seen as 'extras', consequently budgeting for them was difficult and often prioritised last over essential items such as food, lighting, and heating.  Although nearly all women reported that they had resorted to using toilet paper or tissue at some point to prevent leakage, often on their first day of menses (when unprepared for their period), for some, however, this was a usual course of action when they were short of money. Indeed, improvisation of menstrual absorbent, using items such as toilet roll, hand towel, pillowcase, socks, incontinence sheets, cotton wool or sponge, was a common solution to not being able to afford products on occasion and described or agreed (in FGDs) by most of the women.

P1 "I've had to use socks before today"
P7 "I was just about to say, thank god you said that" A few women, unable to budget for or afford menstrual products, reported having to borrow pads or tampons or even shoplift as a last resort. These women appeared embarrassed about their actions.
One woman admitted to having engaged in sex work to purchase menstrual products. I "You also mentioned that you did some sex work, to get money" P "yeah, years ago" I "erm did you ever exchange sex for money so you could buy menstrual products?" P "yeah, yeah definitely"

P7 "you can't afford to go and buy like 7 packets, can't afford to just go pay 3,4 pound odd
(IDI01 Supported accommodation).
Participants who complained of heavy bleeding reported they had to use many products and therefore spent 'a fortune' each month.
When asked, nearly half of our participants felt that menstrual products were "well expensive" although most resorted to purchasing shops' own-brand products when possible, going to discount shops rather than local corner shops or supermarkets to get their products at the cheapest price.
"I think the pound shop is great cos otherwise corner shops or even the big supermarkets, tampons they're sort of £2.50, or £3, so if you go to the pound shop they're only a pound." Not all the women shared these views. A few participants thought that menstrual products were affordable, with one woman having the view that they are essential, so women must buy them regardless of the price. However, as essential items, many participants felt that they should be provided free, comparing them to condoms, and often remarking that if men required similar items, they would be made freely available. reusable sanitary pads had a negative response, finding the concept "backward", "dirty" and "timeconsuming". The increased washing involved and maintaining good hygiene when in public was a particular concern for these participants.

Access to Public WASH Facilities:
When asked about managing menstruation in public, the majority of the women's responses were negative. Topics discussed were the lack of access to and payment for toilet facilities, disposing of products, and keeping clean during menses. Having to pay to use public toilets was acknowledged as a problem, and whilst some participants were seemingly more accepting of the situation, others were aggrieved by what they felt was an unfair situation, further compounded by the lack of available facilities. Women noted there used to be more public toilet facilities in the community, but these are now few or non-existent in some areas. Some women spoke of finding restaurants with free facilities to use, but described difficulties, as many are for customer use only. This resulted in their having to purchase something (which they could ill-afford) or being refused entry, which was described as shameful.
''They'd say "Toilets not working" I just think they didn't want me in you know to go and change" (IDI01 Supported accommodation).
Without prompt, a participant brought up the difficulties of menstruating whilst living on the streets, and commented on the struggles with washing and accessing products with her living situation.
Other participants in the FGD agreed and shared similar experiences. Mention was made of occasionally being told to leave the toilets of private food /drink chains on the assumption that they were accessing them to take drugs. Disposal of products did not seem to be an issue for participants however, as women reported using sanitary bins where possible, or they disposed with household waste in their homes.

Organisational Support
Most of the women interviewed at the food bank were first time users of the service and were not aware that this facility provided menstrual hygiene products. Similarly, most participants in one FGD comprising women accessing supported accommodation were surprised when availability of menstrual products was mentioned. There was a lack of dialogue around how the women perceive the services to support their menstrual needs. None of the women described the organisations as having any part in their menstrual management.
On the other hand, the staff interviewed, spoke of their organisations providing free menstrual products, relying on donations to supply these items. The foodbank buys and restocks additional sanitary items if their donations are depleted, to ensure they have a continuous supply for service users. When relying on donations, staff reported they could only offer a small range of products and could not indulge women's preferences for specific products. The supported accommodation varied on what additional resources they provided, some donating underwear and clothes to women, and others allowed access to washing machines within their services.
Staff reported that they did not discuss menstruation with the women routinely. Those from the supported accommodation sites acknowledged they had little discussion around menstrual health with their female service users, despite sexual health being part of their remit of care.

"we work in a women's service, … for women, about women but I think it's just because of the whole area of it, it's [menstruation] not on our radar its kinda just pushed to one side"
(Staff IDI03 Supported accommodation).
'the staff need to put out the support side of it for the well-being you know, asking them, are your periods regular , reminding them we've got products, asking them if they need products".
However, whilst they appeared overall to think it would be useful to the women, they felt ill prepared to have such conversations as they had received no training. Further, they acknowledged that having male workers discuss these issues could be problematic.

Potential solutions to period poverty issues
Both women and staff were asked their opinion on potential solutions to reduce period poverty. The most common suggestion, often said unprompted by both women and staff, was that menstrual products should be free. During these conversations, the situation in England was often compared to Scotland where free menstrual products are provided. Frequently, participants suggested that products should be free to all or at least to those on low income via government schemes similar to the provision of free prescriptions for people claiming universal credit, or through a token system.
P1 "I just think they should hand them out to you wherever you are".

P2 "they hand condoms out don't they so what's the difference?"
(FGD 02 Supported accommodation) Improving access to, and increasing the number of public facilities, as well as providing complimentary products, were suggestions made or agreed on by many of our participants Improving menstrual health education was also a frequent recommendation made, with a need for men and boys to be taught as well as girls in school and women in the workplace.
A few staff suggested that service providers needed to initiate conversations about menstruation with the women in their care and they further suggested receiving training in menstrual health to increase their knowledge on products and help signpost women to appropriate medical services. (Staff IDI03 Supported accommodation).

Discussion
Despite the current, largely media driven, push to eradicate period poverty, our study remains one of few evidenced based research studies conducted in a HIC on period poverty within a socioeconomically disadvantaged population. We found that menstruation is viewed negatively and experienced as burdensome by most participants, a situation mirroring that for girls and women in LMIC. Despite being set in a HIC, the lack of resources clearly impacted on their perceptions and experience of menstruation, adding to the difficulties of achieving good MHH. To complicate matters, the COVID-19 pandemic will continue to make MHH difficult for a growing number of vulnerable women, and organisational support will be increasingly critical for this expanding population for the foreseeable future. The ramifications of these findings are discussed below.
A dominant theme emerging from our study concerned affordability of menstrual products.
Although women were able to purchase these items at relatively lower cost if they visited budget product shops and bought supermarkets' own-brand products, having to purchase menstrual products at any price was a struggle or balancing act at times. This is a recurring theme in other studies conducted in the UK and US [6,7,10] with Barrington and colleagues systematic review reporting that resource limitations compounded adverse experiences of menstruation [4]. Although menstrual products are essential rather than 'luxury' items, when faced with other spending priorities such as food, lighting and heating they are viewed as more expendable. Women thus must manage their MHH in other ways. Our participants described wearing them for longer than they wished, eeking them out by using items such as toilet tissue, or obtaining them by borrowing, stealing or, in one instance, having sex for money in order to purchase pads. Such ways of improvising or obtaining menstrual absorbents are described frequently in the literature from LMIC [18][19][20][21] and a few studies conducted in HIC [10][11][12]. Interestingly, while the systematic review noted numerous studies reflecting on resource limitations, no findings were reported in relation to improvising or overstaying with products [4]. This may result at least in part from our focus on women living in circumstances of deprivation. It is important to highlight that overstaying with menstrual items is associated with discomfort and chafing, also leakage and staining, creating feelings of fear and shame [18,19,22]. There is some evidence from LMIC to suggest that unhygienic materials may increase the risk of genitourinary infections [23][24][25]. However, the studies in LMIC report that women and girls resort to using rags, mattress stuffing, leaves, grass, ash etc [18,26], items which may be less hygienic than those materials described by women in our study which included toilet or tissue paper, socks, cotton wool and sponges. It is not therefore known whether or to what extent improvising or overstaying with these products may increase risk of infection.
Period poverty is also recognised to be a matter of gender inequity [27,28]. Several of our participants used the simile of needing sanitary products to requiring condoms yet pointing out that the latter are provided free in many places. This was felt to be unfair, with common opinion that if men had periods, they would have access to free products as a matter of course. Menstruation is not a choice, and the argument exists that menstrual materials should be regarded as essential items. Furthermore, if the men making these decisions in government roles had a better context and understanding for women's health, such issues may not exist. Although the UK has recently abolished the 'tampon tax', EU countries are still subject to a 5% levy. Similarly, in the US, sales tax paid on purchase of menstrual products exists because most states consider these products a luxury or, at the least, not a necessity.
We had speculated that for women who struggled to purchase sanitary items each month, reusable products might be one solution, hypothesising that, as occurs in many settings in LIC, the relatively high initial outlay could be borne by donor organisations. We specifically asked women about these products, noting that no individual mentioned them without prior questioning. Although studies suggest that reusable pads and menstrual cups are acceptable and even preferred to other methods in some contexts [29][30][31][32], for the most part, our participants were resistant to this idea. This may have been partly due to a lack of information and knowledge which they admitted to, which can be an initial barrier to acceptance [33]. There were also additional challenges to using washable items such as the requirement for additional washing and drying facilities as well as privacy to do this, which our participants using shared accommodation facilities lacked recourse to, and undoubtedly is an obstacle for those women living on the streets [34] and for those with heavy bleeding [4].
However, the distaste for seeing and touching menstrual blood voiced by some participants in our study also appeared to be a major hurdle. A recent systematic review and meta-analysis of reusable pads found that participants felt 'disgust' at having to wash menstrual blood in a total of 6 qualitative studies [35] while Barrington and colleagues review also noted washing of cloths was 'distasteful' [4]. Further, the drive to use more environmentally friendly products may not be strong amongst vulnerable women in HIC where disposal of commercial sanitary products is relatively easy.
Indeed, when questioned, our participants did not see disposal as an issue for them. Many public facilities including workplaces and entertainment venues have sanitary bins. Domestically, products can be flushed away in toilets or easily binned in refuse facilities, collected on a regular basis. The environmental effects of disposing of commercial pads or tampons tend to be more visible in LMIC where latrines get blocked, bins are not provided, and materials get discarded on waste or other ground [36,37]. A push to promote reusable products for women on low income may have long term benefits for the individual as well as society but would likely need considerable investment including on sensitisation and education before a successful outcome might occur, according to preliminary indications from our small study.
At the time of writing, the UK and most other countries remain in the midst of the Covid-19 pandemic. The pandemic appears to impact on period poverty through a variety of ways. Many individuals and families have suffered financially through loss of work, or reduced earnings, whether permanently or whilst on furlough. This has increased the proportion of population who need financial assistance, including to purchase essentials such as menstrual products. Indeed, the economic impact of Covid-19 has been harder on women than men generally, as they earn less, hold less secure jobs and are more likely to be employed in the informal sector. According to the UN policy brief on the impact of COVID on women 'Their capacity to absorb economic shocks is therefore less than that of men' [38]. Parallel to this, a decrease in supply chain has led to price hikes for many essential household goods, thus also creating more poverty. Repeated lockdowns created severe supply chain bottlenecks that depleted supplies of menstrual products and resulted in price increases, pushing them further out of reach for women on a low income [39]. Anecdotal evidence from charities, dealing with vulnerable individuals and families, indicates demand for assistance has risen [40]. One UK charity 'Bloody Good Period' supplies menstrual products to foodbanks, refugees, homeless persons, those fleeing domestic violence, and community support groups amongst others.
They report supplying almost six times more products since the pandemic began [41]. While, to date, no published UK research study has documented the impact of Covid-19 on period poverty, a recent US survey observed that menstrual product insecurity was strongly predicted by pandemic related loss of income, with low income and / or educational attainment populations at even greater risk [42] We therefore suggest that organisations offering support to women need to widen access generally due to the increasing proportion of vulnerable populations. They need to provide more menstrual products, and make visible the menstrual support they offer. Both women and staff in our study felt this was currently hidden. While there have been recent strides towards combating period poverty in the UK generally, with the abolishment of the 'tampon tax' and free supplies of products to students, this movement needs sustained impetus to achieve greater menstrual equity through supply of free period products or, at the very least, free products to those who can least afford them, following the example of Scotland. Whilst the experience of menstruation will not become a positive one simply through product provision because of the associated physical and psychological burden, noted by Branigan et al [4] as a major outcome for women in many studies, at least there will be one less encumbrance for vulnerable women to bear during their menses.
We note some limitations in our study. Unfortunately, due to the Covid-19 pandemic we were unable to achieve the number and range of FGD and IDI that we anticipated. These may have given us additional insight. However, we were struck by the recurring themes that emerged, with remarkably similar viewpoints from women irrespective of data collection method used. This gives us confidence that we have been able to provide a snapshot of the key issues emerging from the perspectives of women living under impoverished circumstances. A second limitation concerns the very differing positionality of participants to the interviewers / moderator. Although some participants may only currently be living under difficult circumstances, we were aware of likely variations in socio-economic circumstances to ours both in terms of wealth, occupation, and education status. It must also be remembered that a significant proportion of our FGD participants were ex-offenders who had spent time in prison. We attempted to negate these differences by offering an 'open mind', reminding participants it was their voices we wanted to hear and trying to connect as 'women' who also have experienced (or experience) menstruation. We were particularly mindful of positionality during analysis, adopting a reflexive stance [43]. Further, it is unusual for small qualitative studies to use such a wide range of interviewer / moderators, which was necessary due to limitations of time and resources. We attempted to attain some uniformity by devising the tools as a group task, and training together so that we all had similar understanding of the direction to take the conversations. We anticipate that individual traits such as mannerisms and common concerns may have enabled us to connect to individuals on a personal basis facilitating open conversation without changing content radically according to the different interviews.

Conclusion
Women in our study reported menstruation as a physical, psychological, and financial impediment.
The implications from this are that their health and well-being suffer as they balance their MHH needs alongside other day to day hardships. It is likely that the Covid-19 pandemic has increased the number of women who are financially vulnerable. Steps to make menstrual products free for all, or at least for those who suffer financial hardship, are necessary to reduce the burden of menstruation and help redress gender inequity. Organisations which support impoverished women need to make provision of their menstrual products more visible in order that their clients are aware they can access these products in emergency. While promotion of reusable products may be one part solution, this will need to be a longer-term aim with consideration of attitudinal change as well as practical solutions related to washing and drying of products for women not living in private accommodation. We recommend further research undertaken amongst women in HIC, as MHH and menstruation itself appears to be a pervasive issue, problematic not just amongst women living in LMIC but for women generally.